Doing it together strengthens families and helps prevent substance use

Where school-based prevention programmes disappoint, family interventions have a better record. According to an authoritative review, the one with the best record of all is the US Families Programme now being tried in Britain. Where does it come from, and what is the evidence? Karol Kumpfer originated the programme.

The Strengthening Families Programmei is one of the few whose substance use prevention credentials have survived rigorous inspection by independent scholars, in this case a British team who singled it out as the most promising “effective intervention over the longer-term for the primary prevention of alcohol misuse”.Their judgement carries considerable weight because it was based on one of the scrupulously scientific Cochrane reviews. An added attraction is that Strengthening Families’ benefits potentially extend to youth crime and anti-social behaviour, educational attainment, and child welfare, consistent with advice that family interventions should not deal with drugs in isolation. Though the programme and most of the research are US-based, at least one British centre is using it to gain these broader benefits ( The British experience) and at another an evaluation is under way ( Accolade from Cochrane review).

Roots: drug using families and primary school children

The study which caught the Cochrane reviewers’ eyes involved a version of the programme designed to be universally applicable to the families of secondary school children and tested on mainly rural, white, intact families. However, its origins were in an attempt to help drug using parents do the best for their primary-school age children.5 Patients at a methadone clinic in Salt Lake City provided the impetus. By improving their parenting, they hoped to help their children avoid replicating their own fates and to achieve happiness and success. In response Karol Kumpfer, a developmental psychologist at the University of Utah, created an intervention to reduce the chances that the 6–10-year-old children of problem drug users would themselves later develop drug problems. She planned to achieve this by “improving parent-child relationships … We try to change the family dynamics, to create a more democratic family where they actually have family meetings, talk together, and plan activities together.”

Careful construction

Work started in 1983 with a review of research on how drug problems and of existing family programmes which might divert this trajectory. Based largely on the Utah team’s own research, a careful unpicking of how the drug problems of parents affect their children established that disorganised stress in the household often results in a lack of consistent and responsible parenting.7 Parents spend relatively little time with their children, particularly ‘quality time’ enjoying joint activities. Stigma and fear of exposure lead to the social isolation of the family and of the child. To their peers, children from these families can seem ‘strange’, unable to engage in the normal give and take of social interaction or to share their homes and their families with their friends.ii The result is an impoverished social environment which lacks adult supports. Family dysfunction takes its toll on the child in the form of emotional stress, low self-esteem, under-achievement at school, conflict at home, and avoidance of intimate relationships. To meet these needs elements were adapted and blended from existing approaches.8 Despite the achievements of some parent-only approaches, Dr Kumpfer believed that the best response would involve the whole family – parents and children. Ironically given its later transformation into an across-the board (‘universal’) prevention programme, she was also convinced that there was a “qualitative difference” between trying to prevent drug abuse in these high-risk families and preventing recreational and experimental drug use by the children of more typical families. What emerged was the first Strengthening Families Programme. Its basic format has remained unaltered. The weekly sessions last two to three hours. For about an hour parallel groups of children and parents from four to 14 families develop their understandings and skills led by two parent and two child trainers. In a second hour parents and children come together as individual family units to practice the principles they have learned.9 The remaining time is spent in logistics, meals, and enjoyable family activities.5 Its tripartite nature (parents only, children only, then the whole family) departed from previous approaches as did the fact that parents put their learning into effect during the 14 sessions – an opportunity to receive immediate feedback from the trainers.8 During parent-child play sessions parents are coached in how to enjoy their children and to reinforce good behaviour. At first the accent is on building up the positives before tackling the more incendiary issues of limit setting and discipline. The programme is highly structured with detailed manuals, videos and activities, but also highly interactive and designed to be adapted sensitively to the participating families.

The first test: parents in drug treatment

The approach was first trialled in Salt Lake City on 90 families with parents in outpatient substance abuse treatment. Though its findings were convincing enough to generate further federal funding, the study was never fully reported in a scientific journal 10 and the accounts we have seem inconsistent. Many studies followed but this remains one of the few to have randomised families to the programme, eliminating the risk that the apparent benefits arose simply because families who opted to undergo it differed from those who did not. Thirty families were randomly allocated to continue with the parent’s normal substance abuse treatment (the controls)9 while 20 each additionally received the Strengthening Families parents’ sessions, these plus the children’s sessions, or the full programme including the parent-child family sessions1 At issue was which approach would generate the greatest before–after improvements. The clear answer was the full programme. Compared to controls, families offered the full intervention improved in parenting, children’s social skills and family relationships. Parents became less depressed and cut their drug use. Children became less aggressive, better behaved, said relationships with other children had improved, and felt more able to express themselves. Among older children could be seen a reduction in the use of tobacco, drugs, and alcohol. The differences were usually substantial and statistically significant. Without family sessions there had been gains in parenting and child social skills but these had not gelled into improved family relationships. It was the package ‘wrapped up’ by parents and children coming together which had made the difference.

Adapted for new populations

A series of trials followed in which Strengthening Families was adapted for and tested on high-risk families with pre-teenage children from disparate backgrounds.Except for two as yet unpublished studies, none were randomised and only one has been published in a scientific journal.Results from one of the randomised studies are still being analysed. It involved not just US but also Canadian families, probably culturally closer to Britain. Participants were families with children aged 9–12 one of whose parents had a drink problem. They were randomly assigned to a minimal contact control group or to Strengthening Families. An initial report on 365 families who completed before-and-after interviews found significant extra parenting gains in the Strengthening Families group, particularly when the child was a boy. One of the largest of the non-randomised studies involved a mainly poor, multi-ethnic sample of 421 parents and their 703 youngsters aged 6–13. Strengthening Families was compared with a local variant which omitted the joint parent-child sessions found so important in the original study. Again their importance was shown when the full programme led to significantly better family environment, parenting, and child behaviour/emotion outcomes. A five-year follow-up of just the Strengthening Families sample found that the gains had largely persisted, but without a control group this finding can only be considered suggestive. In Hawaii an attempt was made to disseminate the programme throughout schools, churches, and public service organisations. Though multiply flawed, a local evaluation which compared a longer ‘culturally appropriate’ version against the original came up with the interesting finding that the customised version was less beneficial – a warning that though they improve recruitment, such modifications can also undermine the programme by departing from core content or principles. In this case a shift from behavioural training to ‘family values’ sessions could have been the culprit. Hawaii also demonstrated that the prospect of multiple benefits can stimulate support from disparate agencies, enabling large-scale implementation. It also underlined the importance of skilled trainers, these big families numbers were best kept low) if drop-out is to be minimised.

Rural black mothers benefit

For America with its large black drug treatment caseload, whether the programme would work with these families was a major issue. An adapted Strengthening Families’ 14-session version has been tested mainly on high-risk families with primary school children, the seven-session version as a universal substance use prevention programme for secondary school children, but both have been used in other roles. For both there is evidence of improved family, parental and child functioning and of a retardation in the uptake of substance use and a reduction in its severity. For drinking in particular, the seven-session programme is considered the most promising approach we have, but research on this version is confined to a few studies in US rural communities, while most research on the 14-session version has consisted of uncontrolled studies. Nevertheless the consistency and bulk of positive findings warrants serious consideration of the approach not just for substance use prevention but as a means of promoting pro-social child development in general. It is feasible to implement in Britain and a formal evaluation is under way. A version was tested on 62 black, single-mother families in rural Alabama in a study which featured a one-year follow-up.Four results echo other work on the programme. First, recruitment beyond women already in treatment at a mental health centre proved difficult. The solution was to employ a recruiter from the same background who enrolled participants from venues such as housing estates, churches, and classes for problem children. ‘Indigenous’ recruiters also proved valuable in later trials. Secondly, over 80% of the recruited families virtually completed the 14 sessions, typical (perhaps after teething problems) of the programme. Thirdly, the most at-risk families made the greatest gains – in this case mothers who used illicit drugs as well as alcohol. Here there was more scope to normalise the children’s and the parents’ functioning, including their drug use. Children of less at-risk families improved only in the areas where they happened to be problematic in the first place. The implication is that the programme works by helping families with relatively severe problems move closer to the normal range. For those already within this range, it makes less difference. Lastly, the degree to which parents spoke up in the group sessions made no difference to how much they and their children profited from them – a finding later replicated.

Black drug using fathers queue up to join

The replication came in research on black fathers with 6–12-year-old children. In preparation the Alabama manual was tailored for the inner city and renamed the ‘Safe Haven Programme’. It was trialed on the residents of a Salvation Army drug treatment centre in Detroit, using drug counsellors as leaders. Again the recruiting agent was crucial, a charismatic ex-addict drug counsellor. Another typical feature was the integration of the programme into the life of ordinary community venues (local churches at night), destigmatising participation and enhancing sustainability. Also typical was the provision of child care, meals, transport, and other basic supports, much from church members or the treatment agency. These promoted recruitment and retention as did the advent of the specially tailored programme.vii At first low, the retention rate rose to 80% where it remained for four years as applicants came to exceed capacity. Within two years, 88 families had entered the programme. Most had below-poverty incomes and half the children had fallen seriously behind at school, but still 58 families came to at least 10 of the 12 sessions.For the analysis they were split into families whose adults (not just the father) consumed higher versus lower amounts of alcohol and illicit drugs. Before-to-after gains were concentrated in the high drug use families where there were substantial improvements in family and parental illicit drug use, parental depression, confidence in parenting ability, time spent with the children, in the childrens’ delinquency, aggression, and withdrawn or compulsive behaviour, and some improvements in family ‘atmosphere’. Parents also reported significant improvements in their child’s relationship with school.

Feel the weight

Though encouraging, in both studies of black families parents chose to commit to the sessions,viii giving the intervention a head start by selecting out less committed families, and neither had a control group who did not go through the programme. Without this we cannot know whether in these families the improvements would have occurred anyway Practice points from this article This systematic review points to the potential value of the Strengthening Families Program … for the primary prevention of alcohol misuse.

Accolade from Cochrane review Strengthening Families received a boost when a Cochrane review team led by Professor David Foxcroft singled it out as the most promising “effective intervention over the longer-term for the primary prevention of alcohol misuse”. Foxcroft’s team examined over 600 reports of studies of psychosocial or educational interventions intended to prevent alcohol use or misuse by young people. Just 56 were relevant and rigorous enough to be included in the review, and just three reported alcohol use or misuse reductions which persisted over a follow-up period of at least three years. One was the seriously flawed study of Life Skills Training analysed previously in and another investigated an approach tailored for Native Americans. That left Strengthening Families, specifically the study in Iowa where the seven session version was offered across the board to families with children in the early years of secondary school. This featured a “strong design, and … a consistent pattern of effectiveness across the three drinking behaviour variables”. Unusually, its effectiveness“seemed to increase over time,reflecting the developmentally orientated …model on which the intervention is based”. To the original analysis David Foxcroft added one accounting for children not reinterviewed at the last follow-up. This assumed that their behaviour matched that of children from control group families. The result was an estimate that for every nine children whose families had been offered the Iowa programme, one was prevented from starting to drink, to drink without permission, or getting drunk; the last two were statistically significant. These ratios were around twice as good as those for the other two programmes and more consistent across different drinking measures. It was enough to persuade Professor Foxcroft to call for a project to “translate, develop and pilot the Strengthening Families Programme in the United Kingdom”. One such trial is under way, but using it to help troubled families rather than as a universal intervention. Run by the Trust for the Study of Adolescence, the project’s main aim is to test whether involving young people in a family programme is more effective than parenting programmes focused on parents or carers. Participants will be drawn from families referred by the courts because of the behaviour of their children. One of the five services in the study is using Strengthening Families as an example of a whole-family approach. The project ends in August 2004.